The Store-and-Forward Telemedicine Service User-satisfaction Questionnaire: Development and validation of a questionnaire to monitor and assess health care providers' experiences

INTRODUCTION

With wider adoption of store-and-forward telemedicine accelerating, particularly post-coronavirus disease 2019, it is essential to understand health care providers' (HCPs) satisfaction with digital solutions offered by telemedicine organizations to (continuously) guarantee service quality. We developed the Store-and-Forward Telemedicine Service User-satisfaction Questionnaire to monitor and assess HCPs' experiences with contracted telemedicine organizations.

METHODS

Questionnaire construction (phase 1) consisted of exploratory literature search on validated telemedicine satisfaction questionnaires, a telemedicine domain and human factors expert focus group, stakeholder focus group (customer service employee and telemedicine account managers), and two pre-testing rounds among 18 HCPs. The pilot questionnaire (phase 2) was sent to 2179 HCPs for validity and reliability assessment.

RESULTS

Phase 1: Two validated questionnaires (73 items overall) were used as input for Store-and-Forward Telemedicine Service User-satisfaction Questionnaire. Revisions resulted in 61 items. Phase 2: the pilot 61-item Store-and-Forward Telemedicine Service User-satisfaction Questionnaire instrument was completed by 181 of 2179 invited HCPs. Forty-one mandatory items of the pilot Store-and-Forward Telemedicine Service User-satisfaction Questionnaire rated on a 5-point Likert scale were included in psychometric analyses and resulted in six reliable scales: training, communication, organization policy and strategy, interaction platform, usage platform, and working conditions.

DISCUSSION

The Store-and-Forward Telemedicine Service User-satisfaction Questionnaire is a reliable and valid questionnaire for measuring HCPs' satisfaction with store-and-forward telemedicine services as part of a continuous quality improvement cycle. Reimbursement questions were excluded due to low response. As adoption of telemedicine may be impeded by financial compensation issues, this requires consideration in future telemedicine questionnaires. Store-and-Forward Telemedicine Service User-satisfaction Questionnaire including video consultation items is needed to monitor also synchronous services as these expanded in the coronavirus disease 2019 pandemic.

Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study

BACKGROUND

Despite the increase in use and high expectations of digital health solutions, scientific evidence about the effectiveness of electronic health (eHealth) and other aspects such as usability and accuracy is lagging behind. eHealth solutions are complex interventions, which require a wide array of evaluation approaches that are capable of answering the many different questions that arise during the consecutive study phases of eHealth development and implementation. However, evaluators seem to struggle in choosing suitable evaluation approaches in relation to a specific study phase.

OBJECTIVE

The objective of this project was to provide a structured overview of the existing eHealth evaluation approaches, with the aim of assisting eHealth evaluators in selecting a suitable approach for evaluating their eHealth solution at a specific evaluation study phase.

METHODS

Three consecutive steps were followed. Step 1 was a systematic scoping review, summarizing existing eHealth evaluation approaches. Step 2 was a concept mapping study asking eHealth researchers about approaches for evaluating eHealth. In step 3, the results of step 1 and 2 were used to develop an "eHealth evaluation cycle" and subsequently compose the online "eHealth methodology guide."

RESULTS

The scoping review yielded 57 articles describing 50 unique evaluation approaches. The concept mapping study questioned 43 eHealth researchers, resulting in 48 unique approaches. After removing duplicates, 75 unique evaluation approaches remained. Thereafter, an "eHealth evaluation cycle" was developed, consisting of six evaluation study phases: conceptual and planning, design, development and usability, pilot (feasibility), effectiveness (impact), uptake (implementation), and all phases. Finally, the "eHealth methodology guide" was composed by assigning the 75 evaluation approaches to the specific study phases of the "eHealth evaluation cycle."

CONCLUSIONS

Seventy-five unique evaluation approaches were found in the literature and suggested by eHealth researchers, which served as content for the online "eHealth methodology guide." By assisting evaluators in selecting a suitable evaluation approach in relation to a specific study phase of the "eHealth evaluation cycle," the guide aims to enhance the quality, safety, and successful long-term implementation of novel eHealth solutions.

Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study

BACKGROUND

Despite the increase in use and high expectations of digital health solutions, scientific evidence about the effectiveness of electronic health (eHealth) and other aspects such as usability and accuracy is lagging behind. eHealth solutions are complex interventions, which require a wide array of evaluation approaches that are capable of answering the many different questions that arise during the consecutive study phases of eHealth development and implementation. However, evaluators seem to struggle in choosing suitable evaluation approaches in relation to a specific study phase.

OBJECTIVE

The objective of this project was to provide a structured overview of the existing eHealth evaluation approaches, with the aim of assisting eHealth evaluators in selecting a suitable approach for evaluating their eHealth solution at a specific evaluation study phase.

METHODS

Three consecutive steps were followed. Step 1 was a systematic scoping review, summarizing existing eHealth evaluation approaches. Step 2 was a concept mapping study asking eHealth researchers about approaches for evaluating eHealth. In step 3, the results of step 1 and 2 were used to develop an "eHealth evaluation cycle" and subsequently compose the online "eHealth methodology guide."

RESULTS

The scoping review yielded 57 articles describing 50 unique evaluation approaches. The concept mapping study questioned 43 eHealth researchers, resulting in 48 unique approaches. After removing duplicates, 75 unique evaluation approaches remained. Thereafter, an "eHealth evaluation cycle" was developed, consisting of six evaluation study phases: conceptual and planning, design, development and usability, pilot (feasibility), effectiveness (impact), uptake (implementation), and all phases. Finally, the "eHealth methodology guide" was composed by assigning the 75 evaluation approaches to the specific study phases of the "eHealth evaluation cycle."

CONCLUSIONS

Seventy-five unique evaluation approaches were found in the literature and suggested by eHealth researchers, which served as content for the online "eHealth methodology guide." By assisting evaluators in selecting a suitable evaluation approach in relation to a specific study phase of the "eHealth evaluation cycle," the guide aims to enhance the quality, safety, and successful long-term implementation of novel eHealth solutions.

The Value of Teledermoscopy to the Expertise of General Practitioners Diagnosing Skin Disorders Based on ICD-10 Coding

Early recognition of skin cancer is vital to enhance patient outcomes. Teledermoscopy (TDsc), a telemedicine service, supports general practitioners (GPs) in gaining fast access to dermatologists' feedback to detect skin cancer. This study aimed to assess if GPs gain expertise in diagnosing skin disorders after continued use of TDsc, based on diagnosis classification by the International Statistical Classification of Diseases and Related Health Problems (ICD-10). A retrospective study was conducted on TDsc consultations sent by GPs to teledermatologists in the Netherlands (July 2015 - June 2018). GP sensitivity and confirmed cases in diagnosing skin disorders slightly increased over time. However, the total positive predictive value showed a decrease. In three years, 43 melanomas were diagnosed by the TD for which the GP did not provide a (correct) pre-diagnose. Though GPs appear to improve their expertise in skin disorder detection after continued TDsc use, TDsc remains imperative to early melanoma detection.

Is Teledermoscopy Improving General Practitioner Skin Cancer Care?

Skin cancer incidences have tripled in the Netherlands for the last twenty years and are expected to increase even more in the coming years. Teledermoscopy (TDsc) is implemented in Dutch practice to support and enhance early skin cancer detection by general practitioners (GPs) through remote consultation with dermatologists. This study assesses the effect of TDsc consultation on the quality and efficiency of skin cancer care in the primary setting by analyzing 10,184 TDsc consultations.

Improving cooperation between general practitioners and dermatologists via telemedicine: study protocol of the cluster-randomized controlled TeleDerm study

BACKGROUND

Internationally, teledermatology has proven to be a viable alternative to conventional physical referrals. Travel cost and referral times are reduced while patient safety is preserved. Especially patients from rural areas benefit from this healthcare innovation. Despite these established facts and positive experiences from EU neighboring countries like the Netherlands or the United Kingdom, Germany has not yet implemented store-and-forward teledermatology in routine care.

METHODS

The TeleDerm study will implement and evaluate store-and-forward teledermatology in 50 general practitioner (GP) practices as an alternative to conventional referrals. TeleDerm aims to confirm that the possibility of store-and-forward teledermatology in GP practices is going to lead to a 15% (n = 260) reduction in referrals in the intervention arm. The study uses a cluster-randomized controlled trial design. Randomization is planned for the cluster "county". The main observational unit is the GP practice. Poisson distribution of referrals is assumed. The evaluation of secondary outcomes like acceptance, enablers and barriers uses a mixed-methods design with questionnaires and interviews.

DISCUSSION

Due to the heterogeneity of GP practice organization, patient management software, information technology service providers, GP personal technical affinity and training, we expect several challenges in implementing teledermatology in German GP routine care. Therefore, we plan to recruit 30% more GPs than required by the power calculation. The implementation design and accompanying evaluation is expected to deliver vital insights into the specifics of implementing telemedicine in German routine care.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00012944 . Registered prospectively on 31 August 2017.

Potential effect of patient-assisted teledermatology on outpatient referral rates

We carried out a pilot study on the feasibility and accuracy of store-and-forward teledermatology based on patient-provided images and history as a triage tool for outpatient consultation. Patients referred by their general practitioner provided a history and images via the Internet. The information was reviewed by one of 12 teledermatologists and the patient then visited a different dermatologist in person within two days. Three independent dermatologists compared the remote and in-person diagnoses in random order to determine diagnostic agreement. Broader agreement was also measured, by comparing the main disease groups into which the two diagnoses fell. The teledermatologists indicated whether an in-person consultation or further investigations were necessary. There were 105 eligible patients, aged four months to 72 years, who were willing to participate. For the 96 cases included in the analysis, complete diagnostic agreement was found in 41% ( n= 39), partial diagnostic agreement in 10% ( n= 10) and no agreement in 49% ( n= 47). There was disease group agreement in 66% of cases ( n= 63). Nearly a quarter (23%) of participating patients could have safely been managed without an in-person visit to a dermatologist.

Two Decades of Teledermatology: Current Status and Integration in National Healthcare Systems

Teledermatology, originating in 1995, has been one of the first telemedicine services to see the light of day. Two decades of teledermatology research is summarized in this review. A literature search was conducted in PubMed. Search terms included “teledermatology,” “teledermoscopy,” “tele wound care,” “telederm*,” “(dermatology OR dermoscopy OR wound care OR skin) AND (telemedicine OR ehealth or mhealth OR telecare OR teledermatology OR teledermoscopy).” Inclusion criteria were (i) Dutch or English written papers and (ii) publication year from 2011 to present or (iii) (systematic) reviews with publication year before 2011. One hundred fourteen publications and 14 (systematic) reviews were included for full text reading. Focus of this review is on the following outcomes: (i) actors (primary, secondary, tertiary), (ii) purposes (consultation, triage, follow-up, education) and subspecialties (tele-wound care, burn care, teledermoscopy (teledermatoscopy), teledermatopathology, and mobile teledermatology), (iii) delivery modalities and technologies (store and forward, real-time interactive, and hybrid modalities using web-based systems, email, mobile phones, tablets, or videoconferencing equipment), (iv) business models, (v) integration of teledermatology into national healthcare systems, (vi) preconditions and requirements for implementation (security, ethical issues, responsibility, reimbursement, user satisfaction, technique, and technology standards), and (vii) added value.

To conclude, teledermatology is an efficient and effective healthcare service compared to in-person care. Teledermatology reduces patients’ travel time and waiting time, avoids (unnecessary) dermatologic visits, and improves access of care to underserved patients.

Automatic differentiation of color fundus images containing drusen or exudates using a contextual spatial pyramid approach

We developed an automatic system to identify and differentiate color fundus images containing no lesions, drusen or exudates. Drusen and exudates are lesions with a bright appearance, associated with age-related macular degeneration and diabetic retinopathy, respectively. The system consists of three lesion detectors operating at pixel-level, combining their outputs using spatial pooling and classification with a random forest classifier. System performance was compared with ratings of two independent human observers using human-expert annotations as reference. Kappa agreements of 0.89, 0.97 and 0.92 and accuracies of 0.93, 0.98 and 0.95 were obtained for the system and observers, respectively.

Telepulmonology and telespirometry

Taking and interpreting spirometry tests has proven difficult in primary care practice. This may lead to mis- or underdiagnosis of pulmonary diseases, among others chronic obstructive pulmonary disease. Telespirometry and telepulmonology consultation (TPC) may play a role in monitoring and improving the quality of the spirometry tests, supporting GPs in interpreting spirometry test results and reducing the number of physical referrals to the pulmonologist. In telespirometry up to 10% of spirometry results uploaded by GPs were randomly sent to a pulmonologist. Both the GP or practice nurse and the pulmonologist interpreted the spirometry results and gave their diagnostic findings. Additionally the pulmonologist assessed the quality of the test. In TPC a GP could digitally consult a pulmonologist for advice or referral of patients. On sending and closing the TPC consult the GP was presented a number of questions. Based on these questions the percentage of prevented physical referrals and the educational effect experienced by the GPs were determined. Almost a third of the 227 telespirometry tests was of Moderate or Bad quality. The Kappa of the interobserver agreement on diagnostic findings between GP and pulmonologist was 0.38. Between April 2009 and January 2014, GPS sent 4.488 TPCs to pulmonologists. Sixty-nine percent of the TPCs were sent to gain advice, the others were sent in order to prevent a physical referral. Overall telepulmonology reduced the number of physical referrals by 22%. In 90% of the TPCs the GPs indicated they had learned from the consult.

Telepulmonology: effect on quality and efficiency of care

BACKGROUND

Interpreting spirometry results has proven challenging in primary care practice, among others potentially leading to under- and misdiagnosis of COPD. In telepulmonology a general practitioner (GP) digitally consults a pulmonologist to support the interpretation of spirometry results. This study assessed the effect of telepulmonology on quality and efficiency of care.

METHODS

Quality of care was measured by five indicators, among others the percentage of TelePulmonology Consultations (TPCs) sent by GPs for advice, percentage of those TPCs resulting in a physical referral, and educational effect of telepulmonology as experienced by GPs. Efficiency was defined as the percentage of prevented unnecessary physical referrals of patients to the pulmonologist.

RESULTS

Between April 2009 and November 2012 1.958 TPCs were sent by 158 GPs to 32 pulmonologists. Sixty-nine percent of the TPCs were sent for advice. Based on the advice of the pulmonologist 18% of these TPCs led to a physical referral of patients who would not have been referred without telepulmonology. Thirty-one percent of the TPCs were intended to prevent a physical referral, 68% of these actually prevented a physical referral to a pulmonologist.

CONCLUSION

The results show telepulmonology can contribute to quality of care by supporting GPs and can additionally prevent unnecessary physical referrals.

Accuracy and reliability of teledermatoscopy with images taken by general practitioners during everyday practice

We assessed the accuracy and reliability of teledermatoscopy with images taken by a general practitioner (GP) compared to face-to-face dermatological examination. GPs selected patients for teledermatoscopy and took both macro and dermatoscopic photographs. Patients were then referred to the local dermatologist for face-to-face examination. Accuracy and inter-observer reliability were calculated for the diagnosis and management plan. Image quality was rated by two observers on a three-point scale. A total of 108 teledermatoscopy consultations sent by 13 GPs were assessed by four dermatologists. Agreement was 0.61 (kappa) on diagnostic group and 0.23 on management plan. The inter-observer reliability was 0.65 on diagnostic group and 0.36 on management plan. The image quality was reported as bad in 36% of cases, reasonable in 28% and good in 36%. Agreement for cases with good quality images was 0.66 on diagnostic group and 0.42 on management plan. Teledermatoscopy in general practice had overall a lower accuracy and reliability than face-to-face consultation. In cases where a good quality image was reported, the accuracy increased, which emphasises that teledermatoscopy is highly dependent on a good quality images.

Telepulmonology in the Netherlands: effect on quality and efficiency of care

In telepulmonology a general practitioner (GP) digitally consults a local pulmonologist. This study assessed the effect of telepulmonology on quality and efficiency of care. Efficiency of care was measured as the percentage of prevented physical referrals. Quality of care was measured using 5 indicators. Thirty-one percent of the TelePulmonology Consultations (TPCs) were sent to prevent a physical referral, the other TPCs were sent to ask for advice of the pulmonologist. Sixty-eight percent of the TPCs sent to prevent a physical referral indeed prevented a physical referral. Eighteen percent of the TPCs sent for advice resulted in a physical referral on advice of the pulmonologist. These patients would not have been referred without telepulmonology.

Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost

BACKGROUND

Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed.

OBJECTIVES

This study prospectively investigated the effect of teledermatology on efficiency, quality and costs of care when integrated in daily practice and applied following patient selection by the general practitioner (GP).

METHODS

Teledermatology consultations between GP and regional dermatologist were performed in daily GP practice in the Netherlands. Efficiency of care was measured by the decrease in the number of physical referrals to the dermatologist. Quality of care was measured by the percentage of teleconsultations for second opinion, physical referrals resulting from these teleconsultations, the response time of the dermatologists and educational effect experienced by the GP. Costs of conventional healthcare without teledermatology were compared with costs with teledermatology.

RESULTS

One thousand, eight hundred and twenty GPs and 166 dermatologists performed teledermatology, and 37,207 teleconsultations performed from March 2007 to September 2010 were included. In the group of patients where the GP used teleconsultation to prevent a referral (n =26,596), 74% of physical referrals were prevented. In the group of patients where the GP used teleconsultation for a second opinion (n =10,611), 16% were physically referred after teleconsultation. The prevented referral rate in the total population was 68%. The mean response time of dermatologists was 4·6 h (median 2·0). GPs indicated that there was a beneficial educational effect in 85% of the teleconsultations. The estimated cost reduction was 18%.

CONCLUSIONS

Teledermatology can lead to efficient care probably at lower cost. We are therefore of the opinion that teledermatology following GP selection should be considered as a possible pathway of referral to secondary care.

A pilot study on tertiary teledermatology: feasibility and acceptance of telecommunication among dermatologists

Tertiary teledermatology (TTD), where a general dermatologist consults a specialized dermatologist on difficult cases, is a relatively new telemedicine service. We evaluated TTD in a Dutch university hospital, where 13 general dermatologists used TTD to consult 11 specialized dermatologists and two residents at the university medical centre. We measured the avoided referrals to the university centre, the usability of the system and the user acceptance of it. During a three-month study, general dermatologists consulted via TTD 28 times. In 17 of the consultations (61%), the general dermatologists would have referred their patients to the university centre if teledermatology had not been available. Referral was not necessary after teledermatology for 12 of these 17 consultations (71%). The mean usability score (0–100) of all the users was 80. All dermatologists were satisfied with TTD (mean satisfaction of 7.6 on a 10-point scale) and acceptance was high. The baseline measurements showed that half of tertiary referrals were suitable for TTD. These results suggest that TTD reduces unnecessary physical referrals and that users are satisfied with it. A large-scale evaluation is now required.

The course of chronic plaque-type psoriasis in placebo groups of randomized controlled studies

OBJECTIVE

To determine the outcome in placebo-treated patients with plaque-type psoriasis.

DATA SOURCES

Online search of MEDLINE and EMBASE until January 2001 and the Cochrane Library (2001, issue 1), supplemented by references, reviews, guidelines, and textbooks.

STUDY SELECTION

Randomized controlled induction of remission trials of patients with chronic plaque-type psoriasis with systemic treatments with a placebo group not treated with antipsoriatic medication. Identified studies were examined by 2 independent reviewers. Through MEDLINE, 290 studies could be identified. Twenty-seven placebo-controlled studies were included (488 patients).

DATA EXTRACTION

Two independent reviewers extracted data on first author, year of publication, design, comparison, placebo treatment, number of patients, treatment duration, type of psoriasis and baseline severity in the placebo group, mean relative change in outcome measures, and/or percentage of patients with worsening of psoriasis; no change; minimal, moderate, or good improvement; or complete clearance.

DATA SYNTHESIS

Owing to substantial heterogeneity and differences in the way outcomes were reported, no summary estimates could be obtained. The outcome of placebo treatment was poor in most studies. Some reported a mean relative change of 11% to 47%. The highest percentages of patients ended up in the worsening, no change, or minimal improvement categories. Also, complete clearance was possible. No explanation for the differences in outcome between placebo groups could be found. Description of placebo groups was often insufficient.

CONCLUSIONS

The effect of treatment in placebo groups varied across studies in an unpredictable way. To evaluate the variability, improvement of the standardization of study designs, entry criteria, and outcome measures is necessary in psoriasis trials.

The development of practice guidelines for the treatment of severe plaque form psoriasis

OBJECTIVE

To develop and introduce evidence-based guidelines for the selection of 5 commonly used treatment modalities--UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine--for adult patients with severe plaque form psoriasis.

PATIENTS AND SETTING

Patients, residents, and dermatologists from the Department of Dermatology of the Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands, were involved in this process.

DESIGN

The development process started with a questionnaire to evaluate how patients with severe psoriasis were treated. A systematic literature review was set up to provide evidence-based estimates of effectiveness, adverse effects, and dropout rates. In 2 meetings, the opinion leaders and intended users discussed the results of the questionnaire and systematic review as well as the clinical considerations in the treatment choices. Guidelines were then made regarding the sequence of selection of 5 modalities in the concept of rotational therapy. These guidelines were introduced. Their use was analyzed for 6 months.

RESULTS

Before the guidelines, there was no uniform approach. In the systematic review, 665 studies concerning the treatments were found. Exclusion rates were high. No studies of methotrexate therapy could be included. Photochemotherapy showed the highest average proportion of patients with clearance (70% [6947/9925]) and good response (83% [8238/9925]), followed by UV-B (67.9% [620/913]) and cyclosporine (64% [1030/1609]) therapy. In the second internal meeting, the following sequence for the treatments was defined: UV-B, photochemotherapy, methotrexate, acitretin, and cyclosporine. In 78% (69/88) of patients treated after the introduction, the guidelines were followed to determine the treatment choice.

CONCLUSIONS

Guidelines for treating severe plaque form psoriasis can be successfully developed, introduced, and implemented and were considered to improve clinical care.

A systematic review of five systemic treatments for severe psoriasis

We systematically reviewed the evidence concerning the ability of five systemic treatments to induce remission in patients with severe psoriasis: ultraviolet B (UVB), photochemotherapy (PUVA), methotrexate (MTX), retinoids (RET) and cyclosporin A (CYA). An elaborate literature search was performed, the validity of studies was assessed, and data were analysed. In total, 89, 193, 101, 155 and 127 studies (n = 665) concerning UVB, PUVA, MTX, RET and CYA were found. The exclusion rate was high, mainly because of concomitant antipsoriatic therapy, outdated dosages or inadequate documentation. No study on MTX could be included. A total of 129 patient series was included in the analysis, reporting on 13,677 patients. Study size-weighted averages of the proportions of patients with clearance and good, moderate and poor response (defined, respectively, as 95-100%, 75-100%, 50-75% and < 50% reduction in the outcome measurements as compared with baseline) were calculated. PUVA therapy was associated with the highest average proportion of patients with clearance (70%), and the highest proportion of patients with good response (83%), followed by UVB (68%) and CYA (64%). Incidence of side-effects per week was highest in the RET group and lowest in the phototherapy groups. This review may provide a basis for the development of guidelines for the treatment of psoriasis. Trials comparing oral modalities applied according to currently accepted standards should also be carried out.

Soluble interleukin-2 receptor (sIL-2R) is a marker of disease activity in psoriasis: a comparison of sIL-2R, sCD27, sCD4, sCD8 and sICAM-1

Psoriasis is a T-cell-mediated inflammatory skin disease which can be treated successfully with immunosuppressive drugs. Our purpose was to evaluate disease activity of psoriasis and the effect of immunosuppressive treatment by monitoring the soluble T-cell products sIL-2R, sCD27, sCD4, sCD8 and sICAM-1. Twenty-two patients were treated orally with escalating dosages of cyclosporin A (n = 17)(3-5 mg/kg/day) or FK506 (n = 5)(0.05-0.15 mg/kg/day). The Psoriasis Area and Severity Index (PASI) was used to monitor clinical activity of psoriasis. Serum samples were analyzed by ELISA. sIL-2R levels showed the highest correlation with psoriasis disease activity (rs = 0.89; p < 0.05). The longitudinal part of this study showed that levels of sIL-2R and sCD27 decreased during immunosuppressive treatment but remained above normal even in patients successfully treated. Our data indicate that sIL-2R levels are well correlated with disease activity in patients with psoriasis. sIL-2R levels closely follow the decrease of disease activity during immunosuppressive treatment.

Efficacy and tolerability of multiple-dose SDZ IMM 125 in patients with severe psoriasis

Although cyclosporin is effective in immunosuppression following organ transplantation and in the treatment of psoriasis, its use is limited by its side-effects, notably impaired renal function and hypertension. As SDZ IMM 125, a new derivative of the cyclosporin family, showed considerable immunosuppressive activity in experimental studies, with less effect on renal function, it was considered a potential successor to cyclosporin for both indications. In this multicentre, double-blind, placebo-controlled study, the efficacy and tolerability of 40, 100, 200 and 400 mg SDZ IMM 125 daily were studied in 59 patients with psoriasis. Patients were followed for a period of 5 weeks (4 weeks treatment, and 1 week post-treatment observation). A dose-dependent effect of SDZ IMM 125 was observed. A significant correlation was found between the dose of SDZ IMM 125 and changes in the sum of severity scores of three indicator plaques. There was a significant decrease in the body surface area affected by psoriasis in the 400-mg group (P < or = 0.01), whereas a decrease of the global psoriasis severity was observed in the 200-mg (P < or = 0.01) and the 400-mg groups (P < or = 0.001). No serious adverse events occurred during the 4 weeks of treatment. Three patients discontinued treatment because of adverse events (one sore throat, two influenza). Clinical adverse events were similar to those reported with cyclosporin, the most frequent being gastrointestinal disturbances. Estimation of renal function indices showed that increases from baseline values were dose-dependent, and appeared to be similar to those seen with cyclosporin.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies to mycobacterial 65-kDa heat shock protein and other immunodominant antigens in patients with psoriasis

An association of microbial agents and autoimmunity has been suggested for the pathogenesis of psoriasis. Mycobacteria are common environmental microbes and their antigens, especially the highly conserved mycobacterial 65-kDa heat shock protein (hps65), have been implicated in the pathogenesis of autoimmune arthritis and other idiopathic diseases. In this context, we investigated a possible mycobacterium-induced humoral immune response in psoriasis. Sera from 17 patients with chronic plaque-type psoriasis were studied by immunoblotting using the whole sonicate of Mycobacterium tuberculosis and purified recombinant mycobacterial hsp65. Immunoblot analysis demonstrated that 58% of the psoriasis patients compared to patients with acne and DLE, and normal controls showed strong antibody activity to 65-kDa and 48/45 doublet antigens from M. tuberculosis sonicate, whereas 47% of the patients showed antibody activity to mycobacterial hsp65. Only 10-20% of the patients had an antibody response to 16-kDa and 80-kDa antigens. Similar antibody activity to 65 kDa and 48/45 kDa was also found consistently with eight different sonicated mycobacterial species by immunoblotting, indicating that these seroreactive antigens are crossreactive and are present in common environmental mycobacteria. Antibody activities to both mycobacterial 65-kDa and hsp65 showed a positive correlation (r = 0.76) with the psoriasis disease activity, whereas antibodies to 48/45-kDa doublet antigens showed a weak correlation (r = 0.54). By enzyme-linked immunosorbent assay (ELISA), 47% of the psoriasis patients showed significantly elevated antibody titers to hsp65 (p < 0.003) as compared to control groups, and the antibody response by ELISA also showed a significant positive correlation (r = 0.76) with disease activity. Anti-mycobacterial antibody activity may be related to severity of disease and may be useful in monitoring disease activity in psoriasis.